Patient talks
about pain during entire shift. Patient states he is not on pain medication because
of an exam and the pain is unbearable. Patient statets pain is a 6 out of 10.

Objective: Patient is showing signs of pain which include
diaphoreses, increased heart rate of 102 and increased temperature of 99.8.

Problem

Acute Pain

Long Term:

Client will report
that pain management regimen relieves pain to satisfactory level with acceptable
and manageable side effects by discharge.

Determine the client's
current medication use. Obtain a complete history
of medications the client is taking or has taken to help prevent drug-drug interactions
and toxicity problems that can occur when incompatible drugs are combined or when
allergies are present. The history also provides the clinician an understanding
of what medications have been tried and were or were not effective in treating the
client's pain (APS,
2004).

Client reports that pian is relieved through pain medication
which is the management regimen.Goal
met.

Obtained client current medication list from the MAR
on [date] at 1130.Client’s pain medications
were not given during shift because of an exam performed. I will give report to
nurse to continue medications in the evening.

R/T

Left DVT

Short Term:

Client will us
the pain rating scale to identify current pain and intensity of a 3 on a scale of
0-10 and determine comfort/function by end of shift on [date]

Assess pain in a client
by using a self-report such as the 0 to 10 numerical pain rating scale, Wong-Baker
FACES Scale, or the Faces Pain Scale (see Pain:
Assessment Guide
and Appendix
D). Systematic ongoing assessment and documentation provide
direction for the pain treatment plan; adjustments are based on the client's response
(Berry
et al, 2006).
EB: Single-item ratings of
pain intensity are valid and reliable as measures of pain intensity (Jensen,
2003).
EBN: An investigation of
nursing attitudes and beliefs about pain assessment revealed that effective use
of pain rating scales is often determined by the nurse's personal attitude about
its effectiveness (Layman
Young, Horton & Davidhizar, 2006).

Client used the pain rating scale of 0-10 to report
pain. Patient reported a 6 on pain scale of 0-10 at 0800. Goal met.

Reassessed client at 1300 and pain was still a level
6.

Assessed patient using 0-10 pain rating scale and explained
that 0 is no pain and 10 is the worst pain.